<html>

<head>
{php}html_header_show();{/php}

{literal}

 <style type="text/css" title="mystyles" media="all">

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</head>

<body bgcolor="{$STYLE.BGCOLOR2}">

<p><span class="title">Head Pain and Temporomandibular Jaw Examination</span></p>

<form name="hptje" method="post" action="{$FORM_ACTION}/interface/forms/hp_tje_primary/save.php"

 onsubmit="return top.restoreSession()">

<table>

<tr>

	<td>REFERRED BY &nbsp&nbsp;<input type="text" name="referred_by" size="39"value="{$hptje_primary->get_referred_by()}"></td>

</tr>



<tr>

	<td>CHIEF COMPLAINTS</td>

</tr>

<tr>

	<td><p><textarea name="complaints" cols="75" rows="3" wrap="virtual" >{$hptje_primary->get_complaints()}</textarea></p><br /></td>

</tr>

<tr>

	<td><p>DATE OF ONSET&nbsp;&nbsp;{html_select_date start_year="1910"  time=$hptje_primary->get_date_of_onset() time=$hptje_primary->date_of_onset prefix="date_of_onset_"}</p><br></td>

</tr>

<tr>

	<td>PRECIPITATING/AGGRAVATING EVENT: 	<select name="event"><option name="" value="">{html_options selected=$hptje_primary->get_event() options=$hptje_primary->event_array}</select></td>

</tr>

<tr>

<td><p>Other Explain:&nbsp;<input type="text" name="event_description" value="{$hptje_primary->get_event_description()}" maxlength="255" size="39"></p><br /></td>

</tr>

<tr>

<td><p><input type="checkbox" name="prior_symptoms" value="1" {if $hptje_primary->get_prior_symptoms() eq 1}checked{/if}">&nbsp;Denies presence of symptoms prior to accident &nbsp;&nbsp;&nbsp;<input type="checkbox" name="aggravated_symptoms" value="1" {if $hptje_primary->get_aggravated_symptoms() eq 1}checked{/if}>&nbsp;Affirms aggravation of symptoms after accident</p><br /></td>

</tr>

</table>

<table>



{foreach name=loops item=headings key=title from=$checks}

<tr>

	<td>

		{if $smarty.foreach.loops.first ne 1}<br>{/if}

		{$title}

	</td>

</tr>

<tr>

	<td>

	  {foreach item=row key=row_title from=$headings}

			<tr>

				{if !is_numeric($row_title)}

					<td>{$row_title}</td>

					<td class="form_text">{html_checkboxes name="checks" options=$row selected=$hptje_primary->checks separator="&nbsp;</td><td class=\"form_text\">"}</td>

				{else}

					<td width="20"></td>

					<td colspan="6"><table><tr><td class="form_text">

					

					{html_checkboxes name="checks" options=$row selected=$hptje_primary->checks separator="&nbsp;&nbsp;&nbsp;</td><td class=\"form_text\">"}

					{if $title eq "Teeth"}

						&nbsp;&nbsp;Sore#&nbsp;<input type="text" name="teeth_sore_number" size="1" value="{$hptje_primary->get_teeth_sore_number()}">

						&nbsp;&nbsp;Mobile#&nbsp;<input type="text" name="teeth_mobile_number" size="1" value="{$hptje_primary->get_teeth_mobile_number()}">

						&nbsp;&nbsp;Fractured#&nbsp;<input type="text" name="teeth_fractured_number" size="1" value="{$hptje_primary->get_teeth_fractured_number()}">

						&nbsp;&nbsp;Avulsed#&nbsp;<input type="text" name="teeth_avulsed_number" size="1" value="{$hptje_primary->get_teeth_avulsed_number()}">

					{elseif $title eq "Precipitating Factors" and $row_title eq 2}

						&nbsp;<input type="text" name="precipitating_factors_other_text" size="15" value="{$hptje_primary->get_precipitating_factors_other_text()}">

					{/if}

					</td></tr></table></td>

				{/if}

				

			</tr>

	  {/foreach}

	  

	</td>

</tr>

{/foreach}

</table>

<table>

<tr>

	<td colspan="10">HISTORY OF PREVIOUS TREATMENT</td>

</tr>

<tr>

	<td>&nbsp;&nbsp;&nbsp;A.</td><td colspan="10">Specialty<br>

	(A)Anesthesiologist (C) Chiropractor (D) Dentist (E) ENT (F) Family Physician (H) Hospital ER<br>

	(N) Neurologist (O)Orthopedist (P) Physical Therapist (R)Rheumatologist<br><br></td>

</tr>

<tr>

	<td>&nbsp;&nbsp;&nbsp;B.</td><td colspan="10">Treatment Modalities<br>

	(1)Chiropractic (2)Equilibration (3) Examination (4) Medication (5) MRI (6) Orthodontic (7) Orhtopedic<br>

	(8) Pallative (soft diet, heat, etc.) (9) Physical Therapy (10)Prolotherapy (11)Reconstruction (12) Referal<br>

	(13) Soft Collar (14) Cervical Immobilization (15) Splint Therapy (16) TMJ Surgery (17) X-rays<br><br></td>

</tr>

<tr>

	<td>&nbsp;&nbsp;&nbsp;C.</td><td colspan="10">Effectiveness of Treatment: (N) None&nbsp;&nbsp;(F) Fair&nbsp;&nbsp;(G)Good&nbsp;&nbsp;(E)Excellent<br><br></td>

</tr>

<tr>

	<td>Doctor</td><td>Specialty</td><td>TX Rendered</td><td>Effectiveness</td><td>Date</td>

</tr>

{section name="history" loop=8 start="0"}

<tr>

	<td><input type="text" name="history[{$smarty.section.history.index}][doctor]" size="25" value="{$hptje_primary->history[$smarty.section.history.index].doctor}"></td>

	<td><input type="text" name="history[{$smarty.section.history.index}][specialty]" size="25" value="{$hptje_primary->history[$smarty.section.history.index].specialty}"></td>

	<td><input type="text" name="history[{$smarty.section.history.index}][tx_rendered]" size="25" value="{$hptje_primary->history[$smarty.section.history.index].tx_rendered}"></td>

	<td><input type="text" name="history[{$smarty.section.history.index}][effectiveness]" size="15" value="{$hptje_primary->history[$smarty.section.history.index].effectiveness}"></td>

	<td><input type="text" name="history[{$smarty.section.history.index}][date]" size="10" value="{$hptje_primary->history[$smarty.section.history.index].date}"></td>

</tr>

{/section}

</table>

<table>

<tr>

	<td colspan="3"><br><br>HISTORY OF PREVIOUS ACCIDENTS OR INJURIES</td>

</tr>

<tr>

	<td>Nature of Accident</td><td>Injuries</td><td>Date</td>

</tr>

{section name="previous_accidents" loop=8 start="0"}

<tr>



	<td><input type="text" name="previous_accidents[{$smarty.section.previous_accidents.index}][nature_of_accident]" size="35" value="{$hptje_primary->previous_accidents[$smarty.section.previous_accidents.index].nature_of_accident}"></td>

	<td><input type="text" name="previous_accidents[{$smarty.section.previous_accidents.index}][injuries]" size="25" 	value="{$hptje_primary->previous_accidents[$smarty.section.previous_accidents.index].injuries}"></td>

	<td><input type="text" name="previous_accidents[{$smarty.section.previous_accidents.index}][date]" size="10" 		value="{$hptje_primary->previous_accidents[$smarty.section.previous_accidents.index].date}"></td>

</tr>

{/section}

</table>

<table>

<tr>

	<td>COMMENTS</td>

</tr>

<tr>

	<td><textarea name="comments" value="{$hptje_primary->get_comments()}" wrap="virtual" cols="75" rows="8">{$hptje_primary->get_comments()}</textarea></td>

</tr>

{if $VIEW != true}

<tr>

	<td><input type="submit" name="Submit" value="Save Form">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;

<a href="{$DONT_SAVE_LINK}" class="link" onclick="top.restoreSession()">[Don't Save]</a></td>

</tr>

{/if}

</table>

<input type="hidden" name="id" value="{$hptje_primary->get_id()}" />

<input type="hidden" name="activity" value="{$hptje_primary->get_activity()}">

<input type="hidden" name="pid" value="{$hptje_primary->get_pid()}">

<input type="hidden" name="process" value="true">

</form>

</body>

</html>